It is a poignant example of a common situation in psychiatry. Older psychiatrists were trained during a time when there were few effective psychiatric medications, so they cut their teeth on training in psychotherapy. Not surprisingly, doing therapy is fun--it's involves getting paid for having interesting and intimate conversations with people, and helping them to become happier as a result.

In the old days, psychiatrists were paid very well for therapy. In part, this was due to the law of supply and demand--until the late 1940s, psychiatrists alone were allowed to do psychotherapy. But with World War 2 came a critical demand for more therapists to deal with the psychological needs of veterans. Over the ensuing decades, the NIMH granted funds to train psychologists and other non-MDs to deal with the growing public demand for therapy. As the supply of therapists rose, reimbursement for therapy plummeted.

Of course, as any professional guild must do, the American Psychiatric Association fought this trend ferociously, arguing that only professionals who received medical training had the qualifications to do therapy. In 1949, the president of the APA summarized the opinions of a special "Committee on the Relations of Psychiatry and Clinical Psychology" by saying that the "American Psychiatric Association is strongly opposed to independent private practice of psychotherapy by the clinical psychologists; and The Association believes that psychotherapy, whenever practiced, should be done in a setting where adequate psychiatric safeguards are provided."

To the modern eye it seems absurd that intelligent people could believe that you had to go to medical school to do psychotherapy, but the potential for loss of income often confuses the mind. From the 1950s until the 1980s, the APA continuously lobbied state legislatures to prevent independent credentialing for non-MD therapists, but they eventually lost in every state.

Ironically, many within the APA were eventually happy to off-load their therapy tasks to psychologists and social workers, because a plethora of psychotropic drugs were introduced in the 1980s and 1990s. Psychiatrists no longer needed to do therapy to make good money. But this forced a decision point for many psychiatrists, like Dr. Levin, who loved doing psychotherapy. Would they continue to do psychotherapy--thereby diminishing their incomes--or would they become psychopharmacologists, lucratively churning through patients in 15 minute increments? Dr. Levin chose the latter, and sadly, he is unfulfilled.

Quoting from the New York Times article: “I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.” “I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

Many psychiatrists will recognize the sense of tedium and boredom described by Dr. Levin. He went through psychiatric training to do therapy and is now a pill-pusher.

Of course, one can argue that he is simply living with the consequences of that age-old decision: the choice of higher income, but less fulfilling work. The world is filled with realtors, lawyers, marketers, managers, etc..., who wish they could make their current income doing watercolors or teaching elementary school or writing novels.

If Levin wanted to do therapy, he could, but, as he said in the article, "Nobody wants to go backwards, moneywise, in their career." We all make our decisions.

Are Dr. Levin's patients happy? Harris interviewed six of them who said they were satisfied with his care--but these were presumably chosen by Dr. Levin and may not be representative of his caseload of 1200. This brings up a host of issues that I'll discuss in a future post.

30 comments:

If psychiatrists want to keep from becoming "bored, unfulfilled" pill pushers, we need to provide value-added services and convince people to pay for them.

If all we do is sit around and complain about the state of affairs (while patients tend to be doing fairly well, all things considered), then all we're doing is rearranging deck chairs on our own Titanic.

Patients, intuitively, know they should be getting more attention from their doctors. But I've seen no psychiatrist (apart from Unhinged, chapters 9 and 10) make an argument for why his or her special training/expertise deserves reimbursement above and beyond that given for a 10-minute "med check."

I actually felt bad for him after all the harsh criticism and added a comment to that effect, but my second comment wasn't published. I hope he doesn't have a heart attack or something. He seems like a nice guy and I think he feels guilty. I suspect he used this article to expiate his guilt.

There's just so much you can say in one comment there, and I wish I had said more about how psychiatrists are controlled by everyone and their dog, and in many circumstances forced into this type of practice. I wish people knew that you cannot find an employed (or independent contractor position) where you do anything but dispense drugs. You're not allowed to do anything else. The problem is so much bigger than that one doctor.

It all comes back to: can you have a viable cash practice doing what you love, and the answer is too often, no.

If Levin's patients are not happy, why don't they leave? What worries me most is that he thinks psychopharmacology is so simple. He's fully entitled to choose between income and job satisfaction. Everyone must do that. If someone thinks Levin is overpaid, tell us just how much a psychiatrist with his experience is worth. Per hour, week or year. Keep in mind what you pay an auto mechanic, attorney, accountant, neurosurgeon.

The NY Times article was a horrible portrayal of "modern" psychiatric practice. I am sure Dr. Levin is a good man, but he came off as a greedy creep. "I don't want to know that!" or "Don't tell me, tell your therapist!" etc. Is this man a doctor interested in his patients or what? He even complains about running a few minutes late because a patient dared to try to tell him significant details about the factors related to his (or was it her?) emotional pain. If this is "modern" psychiatry, we are all in trouble.

15 minutes? Perhaps for someone who needs hospitalization. It is a maxim that the bs stops only in the last 7 minutes of psychotherapy anyway. As people are putting on their coats to leave, "Oh doctor, I meant to tell you, I slept with my secretary this week." Or, "I cut myself this week." Or, "Voices started up again."

So why not cut to the chase? Do psychotherapy in 7 minute sessions.

Money is the sincerest valuation of a service or product by a stranger. People can be wrong, such as those who sold their Van Goghs for meals in the 19th Century.

The profession has not made its good case for the highest return on investment in health care.

If you give Dr. Levin $500 a year for 10 med checks, he will return you to your $50,000 a year job, if you had a disabling psychiatric condition. Can't be done with therapy. That is a 10,000% return on investment, with guaranteed preservation of capital.

Buy a gun, rob a bank with it. That has a lower rate of return. Nothing comes close to the value of the restoration of health.

I live in the Washington, DC area and it is fairly common here for psychiatrists to do both therapy and meds. Often, they don't take insurance and their patients simply pay whatever their insurance doesn't pay. That is possible because of the high concentration of highly educated, affluent people in DC and surrounding MD and VA suburbs. I realize in most parts of the country that isn't possible because there aren't enough people who can afford to pay, say, $100-$175 a session out-of-pocket.

Reading the article, I found Dr. Levin and his wife to be quite unsympathetic characters. I recognize that the disconnect between the cost of medical school and training and the amount of reimbursement available for therapy is a serious problem, but I personally would never go to a practice like that.

It also seems to me that there is a conflict of interest when a psychiatrist only sees people for medication. Does Dr. Levin ever tell anyone that they should try therapy alone instead of therapy combined with medication? It seems that would be against his interests, since in that case they wouldn't require his services. Seems like that old "when all you have is a hammer, everything looks like a nail" problem.

While the Times has often served us well in bringing to light some of the profession's dirty secrets and nefarious characters, it's unfortunate they chose such an extreme example as Dr. Levin to illustrate this particular trend. Maybe I'm naive, but I doubt many of us so rigidly enforce the "Whoa, I'm not your therapist, just tell me how you're sleeping" rule or direct office staff to deal with patients in so brutally an efficient manner. I felt dehumanized just imagining myself a patient in his mill of a practice. It's true we all make our choices and there is a middle road in how to practice, regardless of insurance-imposed restraints. I know I'm not alone in thinking the extra dollars from packing in 40 patients a day just aren't worth the sacrifice of quality of life and quality of care.

The "choice" between doing fulfilling psychotherapy and mind-numbing prescription writing is a false one. A psychiatrist can do a few hours of therapy a week and spend the rest of the time doing more lucrative things.

$100 an hour for therapy, while low for a highly trained professional, is not exactly slave wages either.

I do not admire psychologists who have to do psychotherapy all day. If done right, while stimulating, therapy is extremely taxing. Why not have a variety of activities?

One psychiatrist I know divided his overhead by the number of hours in the week and decided he could not "afford" to do psychotherapy.

This ignores the fact that once you've met your overhead, you keep 100% of every additional dollar you earn. By this fellow's reasoning, he could not afford to take a vacation. Probably couldn't afford to sleep.

Does Dr. Levin practice empirically supported talk therapies? Gardiner doesn't say. The Times seems to long for the day of unlimited reimbursement of untested psychoanalytic therapy. I also was surprised that this story struck the editors as news, A1, 3,000 words, above the fold, Sunday issue. Psychiatry has benefited financially from its self-relegation to a drug dispensing professional focus for at least a decade or two. How much of psychiatric training is spent learning empirically supported talk therapies? Harris would have been better off asking these questions, rather than trying to drum up pity for the highly compensated Dr. Levin.

Interesting article, and good comment by Mr. Allen. I work as a private practice therapist and find the work to be fulfilling--but if I was to actually make much money I would have to risk burning myself out with a large number of sessions. I find that for myself about 5-6hours of intense therapy is all I can truly handle, after that my ability to truly listen/connect is sometimes hindered. It is difficult to spend 5+ hours straight with depressed/anxious/socially difficult people without needing a break. Particularly now with what seems to be higher risk clients that do self-harm and other risky coping behaviors that just weren't as common in the 90's and before for outpatient clientele.

To do my job well, I suffer from self-limiting my client base (income) and typically struggle financially. I see other therapists who make good money making 70k+ a year, but they meet with endless streams of clients--and they sometimes brag about their level of detachment. Finding some sort of personal balance in the world of work is often difficult, I would like to have an income that would allow me to justify 8 years of education and debt--but to do my job well and not allow it to be a detriment to my own mental health/relationship-- I choose to suffer from chronically low income.

Dr. Levin sounds like the psychiatrist I'm seeing. I'm being treated for recurring depression/perhaps bipolar 2 and after a decade of trying different polypharmacy cocktails, I'm on one that has helped. Except I am currently sleeping 14-15 hours a day and will most likely have to drop this semester of college -- again!

At an "emergency" appointment recently, the doctor said the sleep problem was a sign that I am seriously depressed. I'm not. My mood is good, I feel optimistic, have interest, etc. I'm just tired, all the time, never feel rested.

He wanted to change my meds -- put me on Pristiq or Cymbalta as we hadn't tried those yet. "Why?" I asked. "Because you're depressed." "No, I'm not." "You can't see that you're depressed." he said. "Maybe the dosages of my current meds could be adjusted? Could it be that they are making me sleepy?" "Well, if you don't want to take the advice of a professional with x years of experience, I can't help you!"

At the end of the 20 mins, I left $200 poorer with no help. And went home to sleep.

After all this time, I am reluctant to change meds, when it would be for symptoms I don't have. My doctor, like Dr. Levin, doesn't have to live with the personal consequences (the TD, acne, weight gain, no sleep for days on end, etc., in my case over the years) of his snap judgements but I do.

I need to find a new doctor but now I'm thinking it's "out of the frying pan into the fire" after reading about Dr Levin. I don't know how to find someone who will listen to me.

This is a stupid post. Everyone knows that psychiatrists have sold out to Big Pharma. So what's your point? Should we feel bad about these people for compromising their ethics as physicians in the pursuit of money? YAWN.

I don't recall any mention in that article that Dr Levin is "wealthy. "Quite the opposite: He chose to practice as he does, at least in part, because he is nearing retirement and short on money, a situation too many people his age face today. If he were wealthy I suspect he would not be working at all, or would be having "fun" doing psychotherapy, probably with wealthy patients who don't really need treatment. But he sure makes a good scapegoat.

I applaud moviedoc's first comment about Levin's seeming "dumbing down" of psychopharmacology. The good Doctor Levin seems to suggest that any idiot with a PDR (and a MD) could prescribe psychotropics, and make a lot of money by setting up a med mill and not even having to listen to your patients problems. Good Lord! On the other hand, I suspect that the Dr. Levin's of the world have now come to rule psychiatry in clinical practice. After all, one just has to watch TV and get prescription advice courtesy of Big Pharma. To wit: "Abilify for depression." And other such nonsense. Maybe Dr. Levin is smarter than we are as he laughs all the way to the bank. Maybe WE have been dumbed down by Big Pharma!

I don't get the point of your question. I'd only criticize someone if I thought they were rationalizing their life choices instead of just admitting that they're in it primarily for the money.

If a psychiatrist wants to choose gold over love, fine (as long as he or she is doing a complete and competent job and not just ignoring important psychosocial considerations in their patients). Then just don't complain about it!

And please don't take my comments to mean that we should not all be working to increase the sorry-ass remuneration psychotherapists get for the valuable services we provide.

Mark Scott - the psychotherapy outcome literature is every bit as biased as the drug literature. I actually agree with you about the analysts, but many of the "empirically-validated" psychotherapies are not much better.

I run down many of the gaping holes in the therapy literature, particularly the relationship-ignoring CBT therapies, in my book.

Patients can always choose whether and how to respond to ANY intervention from a therapist, so psychotherapy studies can never be as precise as other types of scientific investigations. The number of uncontrolled variables is practically infinite.

Dr. Levin's business model may work great with patients whose conditions are in remission, and who don't have adverse drug reactions.

For the rest? Not so much. How can he possibly consider residual/resistant symptoms that a patient may be telling him about, make an informed decision on changes in meds for that individual, and explain any discontinuation issues with the old drug, and side effects of the new med, in 15 minutes?

Or is the patient supposed to have the pharmacist do the actual talking and patient interaction?

It is impossible to do psychopharmacology without cognitive advice and content. The latter is a form of rehab, similar to physical rehab and exercise after an orthopedic operation. It is indispensable to the successful orthopedic operation. No surgeon would denigrate, short change a patient on it without hurting his outcomes.

For example. One has to say this or fail in treatment.

Your Abilify will reduce your impulsivity and will solely give you 5 seconds to think before acting. It does not give you the correct answer about what to do, nor coping skills, nor skills in getting what you want and need.

A year later, patients say, I have been doing it for months. Abilify taught me to think first. I can do it on my own. They stop the Abilify with their doctor, and many are right. They no longer need it, duplicating its effect with irreversibly learned skills.

Those skills are the rehab, the exercise of the operated limb. Does an orthopedic surgeon berate herself for not doing rehab, but for merely prescribing it for others to do? No. Nor should we berate ourselves for not doing extensive psychotherapy. The surgeon may briefly describe the exercise needed for success of the operation to the patients, and so may we. But sitting there practicing repetitive rehab is not the best use of time.

As to conflict of interest evidenced by withholding the possibility of response to psychotherapy.

All professions have a conflict of interest in making more money, the more people have problems, and less the more problems are solved. Professionalism, pride in craftsmanship, and need to enhance reputation are all motivations for accuracy of advice, rather than trying to rip off the patient.

But try to give a bereaved person anti-depressant instead of counseling, they get a bunch of side effects, do not return, and bad mouth the psychiatrist to the referring family doctor or pastor. No psychiatrist will want that.

At least we don't hear stories of Dr Levin falling asleep from boredom during his brief "med checks" -- then blaming the patient, as analysts tend to do: http://nymag.com/print/?/news/features/sleeping-shrinks-2011-3

Psychopharmacology practice is neither boring nor mind-numbing. It is in, fact, a fascinating subspecialty of psychiatry. How can one not be fascinated by the idea that by introducing a chemical into someone's body, we can effect minute molecular changes that can make the difference between being disabled and gainfully employed? In med school, I remember meeting a pediatrician who said "any medical specialty is intellectually stimulating...if it's practiced right." Granted, not all types of practice or specialties are for everyone, and Dr Levin appears to have made some compromises that he finds unfulfilling. But I disagree with this too-common assumption that psychotherapy is interesting and med management boring. This is black and white thinking. It all depends on the practitioner. Some colleagues of mine can't stand practicing psychotherapy--"all those self-centered omphaloskepsing whiners..." ;)

Quite apart from the question of whether therapy should sometimes be offered initially, to see if it helps without medicine, and also setting aside questions as to differences among types of psychotherapy that patients may be offered by the providers of “psychotherapy”, is anyone concerned about ethical and common sense clinical standards if the medicine-prescribing doctor fails to regularly exchange information with the psychotherapist about their shared patient?Docport

Dr Allen: "The number of uncontrolled variables [in psychotherapy studies] is practically infinite."

The same is true for psychopharmacology. A patient may take 20 mg Prozac per day, but he also experiences millions of other neurochemical phenomena (sights, sounds, thoughts, emotions, dreams, ideas-- not to mention foods, drinks, and other exogenous chemicals) in the same 24-hour period. Most are transient, but some have a half-life much longer than that of fluoxetine.

Psychopharmacology is no more "pure" a science than psychotherapy. We just like to think so because we have the collective delusion that brain chemistry is simple.

Routine psychopharm of depression and anxiety is often boring and mind-numbing, which is why most of it is done by primary-care docs as part of general medical care. In contrast, psychopharm of complex, severe, or treatment-resistant cases is a fascinating subspecialty of psychiatry. The article implied that Dr Levin mostly practices the former, not the latter. No wonder he feels unfulfilled.

Meanwhile, the psychiatric generalist maintains a crucial role. Like the generalist in internal medicine, the general adult psychiatrist can treat the great majority of patients who present for care, using combinations of psychotherapy, medication, advice/counseling, and so forth. A minority of patients are referred to (sub-) specialists for specific modalities of psychotherapy, or advanced psychopharm, that the generalist cannot provide.

The tragedy of of our field is NOT that we no longer see every patient for endless psychodynamic treatment. It's that so much of psychiatry has willingly dumbed itelf down, by relegating the psychodynamic perspective to other practitioners. This perspective helpfully informs all mental health treatment, including psychopharm and nondynamic psychotherapies such as CBT. Dr. Levin gave it up for expediency and income, but he realizes he's an "ape with a bone" without it.

Interesting article but I hardly agree with thisThe loss of therapy is not simply a money issue for the psychiatrist but also a change in the way mental illness has evolved. And it is not all bad. We are not "crazy" anymore, we have a "biochemical imbalance". Can you cure a biochemical imbalance with words, or is psychotherapy the most extreme form of placebo ever. Just for thought..Diana Ghelber

Typical impotence we hear from the same person over and over again. While everyone else talks about what can be done and offers suggestions, some wallow in self-pity and expect others to do their work for them. It has grown old to the point that there is no credibility left in such impotent comments.

I think Supremacy Claus is overly confident in his or her view that psychiatry tends to restore health. If that is the case, why is there so much trial-and-error? Why is there so much "treatment resistance"? I know very few psychiatric patients whom have been "restored to health". Perhaps that is part of the field's problem. Therapy, on the other hand, HAS restored normal functioning for many.

"pill-pushing" as practiced by Dr. Levin requires great intelligence, careful followup and constant monitoring of research journals. It requires agressive informed consent. It can go tragically wrong even at major research universities when diagnosis and treatment are agenda driven and political.

Considering the marginal effectiveness of antidepressants over placebos, the significant side effects and that Nemeroff's theory of how serotonin reuptake inhibitors effect mood, a more objective method is needed.

Patients should be protected from psychiatri­sts like Levin who prescribe antidepres­sants. Another non-prescr­ibing mental health profession should supervise the patients progress and a psychiatri­st should be unable to prescribe these very serious drugs without profession­al supervisio­n. Primary care physicians should not be allowed to prescribe this serious class of medication­.

This is the same irresponsible action that resulted in so many bad mortgage loans being written.

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About Dr. Carlat

I am a psychiatrist in Newburyport, Massachusetts and an Associate Clinical Professor of Psychiatry at Tufts Medical School (but note that the opinions expressed in this blog are not those of Tufts). I graduated from the psychiatric residency at Massachusetts General Hospital in 1995, and am the founder and publisher of three CME newsletters, including The Carlat Psychiatry Report. In March 2012, I left the publishing world to work on conflict of interest issues for The Pew Charitable Trusts, as director of the Pew Prescription Project. I returned to Newburyport and Carlat Publishing in September 2014.